Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Friday, November 04, 2005

Putting the Public in Public Health

Okay, I didn't see any Reveres at the conference yesterday, the reason being, it was inhabited almost exclusively by state public health department officials, and the Reveres are academics. The third sector in public health is communities, as represented and empowered (to whatever extent they are, which usually isn't very much) by community based organizations. I am a very unusual beast, having a foot in all three worlds, which makes me tripedal and hence an extraterrestrial.

Anyhow, talking to the assembled multitudes (of about 18) about emergency communication to special populations (see below), I noted that the "plan" for this in most states, as in all other areas of public health emergency preparedness, consists of some exhortations to municipal boards of health to figure out what to do about it. (Viz. the preznit's pandemic flu preparedness plan.) Props to the pathetically tiny state of Rhode Island, however, for actually trying to come up with solutions to this problem.

The Department of Health of the pocket Hercules of states has come up with agreements with local radio stations (of which there are ever fewer as radio studios increasingly consist of a locked room containing a computer that transmits national programming) to run announcements in multiple languages; ditto with the major Providence fishwrapper; and agreements with pharmacy chains to post announcements in the locally relevant languages in their windows. They are also translating sections of the "bug book" -- the state health department's basic manual on the various infectious diseases (kind of like the firefighters hazardous materials manual) into 8 languages, for distribution to local boards of health to be in turn distributed to the communities.

There are some limitations to these strategies and difficulties in implementing them. It seems unlikely that people who don't read English will buy the Providence Journal or tune in to NPR or the hip hop station in the first place -- although their kids might alert them to listen, and bilingual people who read the paper could tear out the announcement and share it with their neighbors. But there's no guarantee that people will trust what they read or hear, or understand it. DoH tried contracting with a minority CBO for a pilot project in which they were to use various strategies -- phone trees, doorknocking, computer phone blasts -- to reach 500 families. Apparently it didn't go real well, but they are planning to try again, with closer involvement with a different CBO.

It seems almost too obvious to point out, but the solution to this problem is that public health authorities need to have close involvement with community based organizations on an ongoing basis, routinely, before there is any emergency. I don't know about your state, but in Massachusetts this used to be the style. My own agency had state contracts for health education and health promotion with specific content in breast and cervical cancer, diabetes, HIV, mosquito borne diseases, etc., but that's been scaled back or eliminated. We had a growing community health movement in which the state trained and supported Community Health Workers to do comprehensive health education and outreach. It still exists, but it's been starved during the recent Republican administrations.

I did a survey several years back which targeted Latina women 40 and older, regarding screening mammography, and other health and health care topics. To pilot test it, I went to a meeting of our breast and cervical cancer peer educators, in an apartmentin a public housing development in North Dorchester. There were probably 15 women there, all Spanish speaking, who responded to our draft survey and had a lively discussion with us about the survey and the topics that it covered. If there had been an emergency back then, whether it was pandemic flu or anything else, we could have mobilized those women. We could have gotten them to a meeting within a few hours, given them orientation and instructions, and sent them out to pass the word to their neighbors. They could have told us what they thought folks wouldn't understand or would have trouble believing or doing, and helped us find solutions. We can't do that any more because the state pulled the plug on the program.

There's a lot more to public health infrastructure than hospitals and stockpiles and disease surveillance systems. We need to build and rebuild community public health organizations and networks. Yes it costs money but it's a lot cheaper than occupying Iraq.